BULLETIN NO - Government of New Jersey
BULLETIN NO. 07-17
TO: ALL NEW JERSEY HEALTH INSURANCE COMPANIES; HOSPITAL SERVICE CORPORATIONS; MEDICAL SERVICE CORPORATIONS; HEALTH SERVICE CORPORATIONS; HEALTH MAINTENANCE ORGANIZATIONS; DENTAL SERVICE CORPORATIONS; DENTAL PLAN ORGANIZATIONS; PREPAID PRESCRIPTION SERVICE ORGANIZATIONS; ORGANIZED DELIVERY SYSTEMS; AND OTHER INTERESTED PARTIES
FROM: STEVEN M. GOLDMAN, COMMISSIONER
RE: AMENDMENTS TO THE HINT FORMS
On March 26, 2007 the Department issued Bulletin No. 07-07, which addressed amendments to the HINT Enrollment Forms, Exhibits 1A and 1B of the Appendix to N.J.A.C. 11:22-3 (Electronic Transmission and Receipt of Health Care Claims - “HINT” Enrollment forms”). It has come to the Department’s attention that the forms in Exhibits 1A and 1B as attached to Bulletin 07-07 do not include the “LOC #s” under the “Activity” section for the “Primary,” “OB/GYN” or “Dentist” entries. Therefore the Department is providing as attachments hereto the corrected form pages that now include spaces for the entry of the “LOC #” information. These forms can be accessed via the Department’s website at: . The Department intends to propose amendments to Exhibits 1A and 1B of N.J.A.C. 11:22-3 to codify the revised forms in the near future.
8/29/07 /s/ Steven M. Goldman
Date Steven M. Goldman
Commissioner
DHT07-06/inoord
|B. [Employee] Information – to be completed |Name (Last, First, MI): |SSN: |
|by the [Employee] | | |
|Home | |Birthdate (mm/dd/yyyy): | Male |
| |Street/Apt:________________________________________________________________________________________ | |Female |
| |Street/Apt:________________________________________________________________________________________ | | |
| |City:___________________________________________________ State:_____ Zip Code: _____________________ | | |
| | |Phone: (_____)________________ |
| | |[Email: _______________________________] |
|Work | | |
| |[Employer] Name:__________________________________________________________________________________ |Phone: (_____)__________________ |
| |Address:__________________________________________________________________________________________ |[Email: _________________________________] |
| |City:___________________________________________________ State:_____ Zip Code: ______________________ |Employment Date: _____/_____/_____ |
| | |Hours worked per week:_________ |
|Activi| Add Remove Continuation Other Change If a name change, indicate prior name: |
|ty | |
| |[Primary LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |
| |address: zip+4 | |No] |
| |] | | |
| |[Ob/Gyn LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |
| |address: zip+4 | |No] |
| |] | | |
| |[Dentist LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |
| |address: zip+4 | |No] |
| |] | | |
|Other Health Coverage? Yes No If yes: |[Other Rx Coverage? Yes No If yes: |
|Payer Name: ____________________________________________________________ |Payer Name: ____________________________________________________________ |
|Policy #: ________________________________________ |Policy #: ___________________________________________ |
|Medicare ID#, if any: |Medicare ID#, if any: ] |
|Previous Coverage? Yes No |Payer Name:____________________________________________________________ |
|If Yes: |Policy #:____________________________ |
|Effective date: _____/_____/_____ Termination date: _____/_____/_____ |[Submit a Certificate of Creditable Coverage] |
|C. Plan Option – to be completed by the [Employee] Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status] |
|D. Other Individuals Covered – to be completed by the [Employee] Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage. Attach additional pages if necessary, with |
|your signature and dated. [Attach proof if full-time post-secondary student.] [Attach proof of disability.] |
|1. Spouse; Domestic or Civil Union Partner |2.Child |3. Child |4. Child |
|Add Remove | Add Remove | Add Remove | Add Remove |
|Other Continue Spouse |Other Continue |Other Continue |Other Continue |
|Continue CU Partner (NJSGC) | | | |
NONGROUP ENROLLMENT/CHANGE REQUEST
|[Carrier Logo] |
|[Carrier Name] |
|A. Type of Activity – to be completed by [Applicant] Refer to instructions [on back] before completing this form. Print clearly. |
|Activity – Check all that apply |Effective Date/ |Reason |
| |Date of Event | |
|ADD | Enrollment of a new [Insured/Enrollee/Subscriber] |_____/_____/_____ |________________________________________________________ |
| |Add Spouse[/Civil Union Partner] |_____/_____/_____ |________________________________________________________ |
| |[ Add Civil Union Partner] |[_____/_____/_____] |[_______________________________________________________] |
| |Add Domestic Partner |_____/_____/_____ |________________________________________________________ |
| |Add Dependent Child |_____/_____/_____ |________________________________________________________ |
| REMOVE | Remove [Insured/Enrollee/Subscriber] |_____/_____/_____ |________________________________________________________ |
| |Remove Spouse[/Civil Union Partner] |_____/_____/_____ |________________________________________________________ |
| |[ Remove Civil Union Partner] |[_____/_____/____] |[_______________________________________________________] |
| |Remove Domestic Partner |_____/_____/_____ |________________________________________________________ |
| |Remove Dependent Child |_____/_____/_____ |________________________________________________________ |
| OTHER | Name Change |_____/_____/_____ |_______________________________________________ |
|CHANGE |Change Plan |_____/_____/_____ |________________________________________________________ |
| |Other |_____/_____/_____ |________________________________________________________ |
| |[Add/Change Office ID Numbers: Primary/OB/Gyn] |_____/_____/_____ |________________________________________________________ |
|B. [Applicant] Information |Name (Last, First, MI): |
|SSN: |Birthdate (mm/dd/yyyy) | Male |[Email:] |
| | |Female | |
|Are you a resident of New Jersey? Yes No |Do you maintain a home in any other state? Yes No If yes: |
| |Name of State:______________________________ Number of months you live there each year: _________ |
|Address |Primary Residence: |Other Residence: |
|Informati|Street/Apt:___________________________________________________________ |Street/Apt:___________________________________________________________ |
|on |Street/Apt:___________________________________________________________ |Street/Apt:___________________________________________________________ |
| |City:___________________________________________________ State:______ Zip Code: _____________________|City:___________________________________________________ State:______ Zip Code: _____________________|
| |Phone: (_____)_________________ |Phone: (_____)_________________ |
| |Your billing address: Primary residence Other residence P.O. Box or Other (specify): |
|Activity | Add Remove Other Change Continue If a name change, indicate prior name: |
| |[Primary LOC#:] ______________________________________________________ |[NPI #:] |[Current Patient: Yes |
| |address: zip+4 | |No] |
| |] | | |
| |[Ob/Gyn LOC#:) _____________________________________________________ |[NPI #:] |[Current Patient: Yes |
| |address:] zip+4 | |No] |
-----------------------
| | |[pic] | | |
| | |State of New Jersey | | |
| | |Department of Banking and Insurance | | |
| | |Legislative and Regulatory Affairs | | |
|Jon S. Corzine | |PO Box 325 | |Steven M. Goldman |
| | |Trenton, NJ 08625-0325 | | |
| | | | | |
|Governor | |Tel (609) 984-3602 | |Commissioner |
| | |Fax (609) 292-0896 | | |
Visit us on the Web at
New Jersey is an Equal Opportunity Employer • Printed on Recycled Paper and Recyclable
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